Akut Karaciğer Yetmezliğinde Yoğun Bakım Yönetimi
Özet
Akut karaciğer yetmezliği hızlı seyirli, ölümcül bir hastalıktır. Tabloya sarılık, koagülopati ve hepatik ensefalopati hakimdir. Sistemik inflamasyon; serebral ödem ve organ fonksiyon bozukluklarının hem gelişimini hem de ciddiyetini yönlendirir. Son on yılda yoğun bakım yönetimindeki gelişmeler ile refrakter intrakranyal hipertansiyona bağlı kayıplar azalmış olsa da zamanında yapılan karaciğer transplantasyonu, seçilmiş hastalarda kesin tedavi olmaya devam etmektedir. Bu yazıda gecikmiş başvurulu parasetamol kullanımına bağlı akut karaciğer yetmezliği olgusunda uygulanan ileri tedaviler geniş olarak ele alınmış ve bilimsel kanıtlar eşliğinde sunulmuştur. Karaciğer yetmezliğinde sağkalımı artırmayı hedefleyen ileri tedaviler, toksinlerin ve inflamatuar mediatörlerin uzaklaştırılmasına dayanırken, aynı zamanda karaciğer transplantasyonu ya da spontan hepatik rejenerasyon beklenirken karaciğerin sentetik ve metabolik fonksiyonunu desteklemeyi amaçlar. Erken renal replasman tedavisi ve potansiyel olarak terapötik plazma değişimi, yakın zamanda akut karaciğer yetmezliği yönetiminde merkezi tedaviler olarak kabul edilmektedir.
Acute liver failure is a rapidly progressive and life-threatening clinical syndrome characterized by jaundice, coagulopathy, and hepatic encephalopathy. Systemic inflammation plays a pivotal role in both the development and severity of cerebral edema and multiple organ dysfunction. Although advances in critical care management over the past decade have reduced mortality associated with refractory intracranial hypertension, timely liver transplantation remains the definitive treatment in carefully selected patients. In this report, advanced therapeutic strategies implemented in a case of paracetamol-induced acute liver failure with delayed presentation are comprehensively reviewed and discussed in light of current scientific evidence. Advanced supportive therapies aimed at improving survival in acute liver failure are primarily based on the removal of circulating toxins and inflammatory mediators, while simultaneously providing support for the liver’s synthetic and metabolic functions as a bridge to liver transplantation or spontaneous hepatic regeneration. Early initiation of renal replacement therapy and, potentially, therapeutic plasma exchange have recently emerged as cornerstone interventions in the contemporary management of acute liver failure.
Referanslar
Kwong S, Meyerson C, Zheng W, et al. Acute hepatitis and acute liver failure: pathologic diagnosis and differential diagnosis. Seminars Diagnostic Pathology 2019; 36: 404–14.
Bernal W, Hyyrylainen A, Gera A, et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients.
Journal of Hepatology 2013; 59: 74–80.
Chung RT, Stravitz RT, Fontana RJ, et al. Pathogenesis of liver injury in acute liver failure. Gastroenterology 2012; 143: e1–7.
Antoniades CG, Berry PA, Wendon JA, et al. The importance of immune dysfunction in determining outcome in acute liver failure. Journal of Hepatology 2008; 49: 845–61.
Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute Liver failure guidelines. The American Journal of Gastroenterology. 2023;118:1128-53.
Larson AM, Polson J, Fontana RJ, et al. Acetaminophen- induced acute liver failure: results of a United States multicenter, prospective study. Hepatology. 2005;42:1364-72
Lee WM, Hynan LS, Rossaro L, et al. Intravenous N-acetylcysteine improves transplant-free survival in early stage non- acetaminophen acute liver failure. Gastroenterology 2009;
137: 856–64.e1.
Walayat S, Shoaib H, Asghar M, et al. Role of N-acetylcysteine in non-acetaminophen-related acute liver failure: an updated meta-analysis and systematic review. Annals of Gastroenterology 2021; 34: 235–40.
Kalal CR, Maiwall R, Choudhary A, et al. Mannitol is comparable to hypertonic saline for raised intracranial pressure in acute liver failure (MAHAL Study): a randomized controlled trial. Digestive Diseases 2022; 40: 607–15.
Kumar R, Shalimar, Sharma H, et al. Prospective derivation and validation of early dynamic model for predicting outcome in patients with acute liver failure. Gut 2012; 61: 1068–75.
Clemmesen JO, Larsen FS, Kondrup J, et al. Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration. Hepatology 1999; 29: 648–53.
Warrillow S, Fisher C, Tibballs H, et al. Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure. Critical Care and Resuscitation 2020; 22: 158–65.
MacDonald AJ, Speiser JL, Ganger DR, et al. Clinical and neurologic outcomes in acetaminophen-induced acute liver failure: a 21-year multicenter cohort study. Clinical Gastroenterology and Hepatology 2021; 19: 2615–25.
European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; Clinical practice guidelines panel; Wendon, J; Panel members; Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I; EASL Governing Board representative; Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. Journal of Hepatology. 2017 May;66(5):1047-1081.
Connelly-Smith L, Alquist CR, Aqui NA, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue. Journal of Clinical Apheresis. 2023 Apr;38(2):77-278.
Cohen J, Aslam M, Pusey CD, et al. Protection from endotoxemia: a rat model of plasmapheresis and specific adsorption with polymyxin B. J journal of Infection Diseases 1987; 155: 690-695.
Nagaki M, Hughes RD, Keane HM, et al. In vitro plasma perfusion through adsorbents and plasma ultrafiltration to remove endotoxin and cytokines. Circulatory Shock 1992; 38: 182- 188.
Krisper P, Haditsch B, Stauber R, et al. In vivo quantification of liver dialysis: comparison of albumin dialysis and fractionated plasma separation. Journal of Hepatology 2005; 43: 451-457.
Evenepoel P, Laleman W, Wilmer A, et al. Detoxifying capacity and kinetics of prometheus--a new extracorporeal system for the treatment of liver failure. Blood Purification 2005; 23: 349-358.
Kapoor D. Molecular adsorbent recirculating system: albumin dialysis-based extracorporeal liver assist device. Journal of Gastroenterology and Hepatology 2002; 17 Suppl 3: S280-S286.
Gashti CN. Membrane-based Therapeutic Plasma Exchange: A New Frontier for Nephrologists. Seminars in Dialysis 2016; 29: 382-390.
Schaefer B, Schaefer F, Engelmann G, et al. Comparison of Molecular Adsorbents Recirculating System (MARS) dialysis with combined plasma exchange and haemodialysis in children with acute liver failure. Nephrology Dialysis Transplantation 2011; 26: 3633-3639.
Vaquero J, Polson J, Chung C, et al. Infection and the progression of hepatic encephalopathy in acute liver failure. Gastroenterology. 2003; 125:755–64
